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The Macstrak Project CCU Case Studies The following is a series of case studies to review different patient types and how they are captured on the form.

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Presentation on theme: "The Macstrak Project CCU Case Studies The following is a series of case studies to review different patient types and how they are captured on the form."— Presentation transcript:

1 The Macstrak Project CCU Case Studies The following is a series of case studies to review different patient types and how they are captured on the form. The information is provided in sequence to reflect the natural progression of a patients care. As the case is presented, mark off the required information in the appropriate fields on your Macstrak form. At the end of each case study, the form will be reviewed with the correct answers supplied. If you have any questions, please refer to your Macstrak manual or contact us at the Macstrak Project Office.

2 The Macstrak Project CCU Case Study

3 The Macstrak Project CCU Case Study FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MIs in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF.

4 The Macstrak Project CCU Case Study FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MIs in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. On 02/03/06 FR presented to the ER with dyspnea at rest and was admitted to the ward service with CHF. He received ASA, an ACE inhibitor and furosemide.

5 The Macstrak Project CCU Case Study FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MIs in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. On 02/03/06 FR presented to the ER with dyspnea at rest and was admitted to the ward service with CHF. He received ASA, an ACE inhibitor and furosemide. The morning of 06/03/06 he becomes increasingly short of breath. He has severe chest congestion. Two hours later he is in acute distress. His BP is 78/42 and HR is 120. He denies any chest pain. He is transferred to the CCU with a diagnosis of CHF.

6 The Macstrak Project CCU Case Study FR arrives in the CCU at 10:30 a.m. He is intubated and ventilated and given dopamine IV. He has an arterial line placed and remains hypotensive despite increasing amounts of dopamine. He also receives furosemide IV. A PA line is placed and confirms an elevated wedge pressure at 28 mmHg and low cardiac output at 3.2 litres/min. At 13:30 he has a VT/VF arrest and is promptly defibrillated. He remains hypotensive and anuric and dies of progressive hypotension at 18:30. His discharge diagnosis is CHF.

7 The Macstrak Project Centre: CCU ICU Date: 20 Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female CCU Case Study FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MIs in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. F R 23 01 20 CCU MACSTRAK X

8 The Macstrak Project Centre: CCU ICU Date: 20 Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female CCU Case Study The morning of 06/03/06 he becomes increasingly short of breath. He has chest congestion. Two hours later he is in acute distress. His BP is 78/42 and HR is 120. He denies any chest pain. He is transferred to the CCU with a diagnosis of CHF. F R 23 01 20 CCU MACSTRAK 06 03 06 X

9 The Macstrak Project Past Medical History : 30 days MI ……………………………. Angina ……………………….. CABG ……………………….. PCI …………………………… CHF ………………………….. TIA/CVA …………………….. Diabetes (oral agents/insulin)... None of the Above……………. CCU Case Study FR is an 86-year-old (DOB: 23/01/20) man with a past medical history of MIs in 1990 and 1994 and 2 episodes of CHF in 1995 as well as a three-day hospitalization three weeks ago for CHF. X XX

10 The Macstrak Project Patient Origin: ER EMS Walk In Dr.s Office/Clinic (Direct) Other Hospital Inpatient Medical Ward Surgical Ward Other ICU Other: ……………… CCU Case Study On 02/03/06 FR presented to the ED with dyspnea at rest and was admitted to the ward service with CHF. He received ASA, an ACE inhibitor and furosemide. X X

11 The Macstrak Project VS at Presentation: (complete for all patients) Dyspnea/Rales: None Mild Mod/Severe Systolic BP: < 100 101-130 131-160 161-190 >190 Heart Rate: < 80 80-100 >100 CCU Case Study The morning of 06/03/06 he becomes increasingly short of breath. He has severe chest congestion. Two hours later he is in acute distress. His BP is 78/42 and HR is 120. He denies any chest pain. He is transferred to the CCU with a diagnosis of CHF. X X X

12 The Macstrak Project CCU Case Study The morning of 06/03/06 he becomes increasingly short of breath. He has severe chest congestion. Two hours later he is in acute distress. His BP is 78/42 and HR is 120. He denies any chest pain. He is transferred to the CCU with a diagnosis of CHF. Admitting Diagnosis: (Check one only) Acute AMI (48 hrs) UA R/O MI UA RSCP NYD CHF Arrhythmia Aortic Dissection Non ACS Pericardial Disease Other: ………………… ACS X

13 The Macstrak Project Acuity: Shift: Diuretics……………………… Inotropes IV………………….. ETT/Vent…………………….. PA Line………………………. TTVP………………………… IABP…………………………. ACS: RSCP - Ischemia – Definite…. – Probable… CK (+ve)………………...…… Troponin (+ve)……………….. NTG IV………………………. Heparin – UFH……………..... – LMWH……………. Other Antithrombin………...… GP 2b/3a Inhibitor IV……...… Clopidogrel (or ticlopidine)..… Cardiac Cath……………….... PCI…………………………... Outcomes: VF/Sustained VT………….… Infarction (new/repeat) *(1) …... Thrombolysis (new/repeat) *(2).. Stroke *(3) ……………………. Major Bleed *(4) ……………… Transfusion………………….. Crs1: ……………………….... Crs2: ……………………..….. None of the Above……….….. RN Initials ………………..…. Date: CCU Case Study DNDNN D FR arrives in the CCU at 10:30. He is intubated and ventilated and given dopamine IV. He has an arterial line placed and remains hypotensive despite increasing amounts of dopamine. He also receives furosemide IV. A PA line is placed and confirms an elevated wedge pressure at 28 mmHg and low cardiac output at 3.2 litres/min. At 13:30 he has a VT/VF arrest and is promptly defibrillated. 06 X X X X X KD

14 The Macstrak Project Discharge Diagnosis: Acute MI Unstable Angina Chest Pain NYD CHF Arrhythmia Other Cardiac Problem: ………….................. Non Cardiac Problem: …..….............………..... Date: 20 Time: CCU Case Study Day Month Year Peak CK: Trop: 06 0306 1830 X At 13:30 he has a VT/VF arrest and is promptly defibrillated. He remains hypotensive and anuric and dies of progressive hypotension at 18:30. His discharge diagnosis is CHF.

15 The Macstrak Project CCU Case Study Discharged To: Cardiac Ward Med/Surg Ward Step Down Unit CV Surgery Other ICU Other Hospital Home Death Other:.............. Discharge Meds: ASA Clopidogrel (or ticlop.) Heparin (UF or LMW) Nitrates (po/top) B Blocker ACEI A2 Blocker Statin None of Above X X At 13:30 he has a VT/VF arrest and is promptly defibrillated. He remains hypotensive and anuric and dies of progressive hypotension at 18:30. His discharge diagnosis is CHF.

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